Imaging On the Edge, Medcon Delivers Multimodality Innovation to Providence Hospital Cath Labs

Gone are unwieldy film canisters and drawers full of files. Patient cath lab reporting is now almost fully automated. Physicians can now read combined cardiac and hemodynamic data in a single report. While Providence Hospital and Medical Centers (Southfield, MI) had some filmless cath labs prior to the project, the move to a filmless, networked management system has reaped multiple rewards for our cath lab: greater productivity, a more efficient use of clinical time, and enhanced patient care. However, our successful conversion to filmless did pose some unique challenges. A notably large-scale project, it involved several modalities as well as connections to numerous clinical and hospital information systems. Providence Hospital and Medical Centers is a 500-bed hospital known for the quality of its cardiovascular care. In 2001, it was named one of the Top 100 Cardiovascular Hospitals in the country by Solucient, and has been a Blue Cross-Blue Shield Cardiovascular Center of Excellence since 1995. The Providence Heart Institute is a full-service cardiology center providing preventive, diagnostic, therapeutic, and rehabilitation services. It handles over 3,000 cath cases each year. All cath and most echo labs are located in the main Southfield campus, while the outlying Novi and Livonia Centers also house echo labs. The three locations are networked via T-1 lines. These labs function together as a unified department, and key to the project was integrating images and information acquired at all locations and then sharing it throughout the entire Heart Institute. Ambitious Goals We had considered digital conversion for some time and identified our goals early on: 1. Create a comprehensive cardiology patient file with integrated cath and echo data. 2. Obtain seamless connectivity with other systems such as hemodynamic and hospital information systems (HIS). 3. Open architecture to simplify interfacing with other systems and eventual creation of an electronic virtual patient record (VPR). 4. A web interface to make cath and echo lab images and information available on the hospital-wide intranet, as well as for telecardiology purposes. 5. Bi-directional telecardiology for exchange of echo images with the sites at Novi and Livonia was critical. 6. Two of our existing cath labs were analog they did not have DICOM output. This was also true for a number of the echo systems. To minimize costs, we wanted to connect with these labs and systems without having to do digital DICOM upgrades. 7. A user-friendly and reliable system with customized interfaces. 8. A range of very specific features, such as facilitating consultations and second opinions over the Internet, as well as communications with referring physicians. Leading the Way Due to the scope of this project, a number of departments were involved: The cath lab clinical team: Dr. Shukri David, Section Chief of Cardiology, the medical directors of the cath lab and interventional cardiology, and myself (Manager of Invasive Cardiology). Christopher Bissell, manager of non-invasive cardiology, and the medical directors of echocardiography and non-invasive cardiology. Overseeing the project on an administrative level, Christopher Southwick, director of cardiology services, ensured the project met expectations from a workflow and hospital management perspective. Also involved were our information technology (IT) department, including applications and networking, and the clinical engineering department. The Search for a Vendor Providence Hospital considered major equipment manufacturers as well as specialized vendors. After reviewing the responses to our RFPs, we found that only a few vendors could meet the demands of the project. Most could not provide connectivity with our analog acquisition devices and wanted us to upgrade to costly DICOM acquisition. Even fewer could provide the integrated cath-echo image management environment we sought. Knowing we would have to live with our decision for a long time, we asked vendors under serious consideration to stage live in-house system demonstrations for doctors and other appropriate staff members. The vendor we ultimately chose, Medcon (Whippany, NJ), demonstrated ultra-fast study retrieval from a DVD jukebox and advanced web publication, including telecardiology with our remote sites. Tailoring the Approach Next, working with our team, the company specified a system according to our needs. The result was our new cath and echo image management and archiving system, which connects three angiography and eight echo systems. Cath labs at the main campus include a GE (Milwaukee, WI) and Siemens analog x-ray angiography (South Iselin, NJ) system as well as one new digital Siemens system with DICOM output. The installation offered instant network access to cardiac procedures stored on a RAID and less than 30-second access to long-term archiving based on a DVD-R jukebox, as well as Medcon’s Direct Read Retrieve software technology. Long-term archiving is situated at the main Southfield facility. T-1 lines provide connection to the outlying facilities. Southfield houses four DICOM echo systems. Echo installations at the outlying Novi and Livonia locations are a mix of DICOM and analog. The new system connected with all acquisition devices DICOM and analog alike. Today, primary reading is done on Medcon TCS viewing stations located throughout the Providence Heart Institute. As part of our fully integrated system, these display both cath and echo images and reports. Our TCS makes cath and echo accessible under a single application. It also stores both modalities in a single DICOM-based patient file. Streamlining Workflow We have found that the system meets the needs of both cath and echo specialists. Each modality has a specific interface, which addresses its specific workflow and provides features for image analysis and reading. We feel it is important to closely review user interfaces before purchasing a system, because they vary widely. If a system interface does not meet physician needs, the purchase could be an expensive mistake. The open architecture of our system allows us to connect with other digital information systems. For example, Medcon’s cath reporting application connects to the Siemen’s CATHCOR® hemodynamic system, allowing hemodynamic information to autopopulate Medcon’s cath reports and databases. It also allows doctors to work in a single application running on a workstation. Physicians need only input the patient summaries and conclusions. Everything else is automatically pulled in. This cath lab report automation is a great time-saver and one of our favorite features (see sidebar). Medcon cath reporting is certified by the American College of Cardiology (ACC) for meeting Core Data Elements standards. This enables our center to participate in ACC’s National Cardiovascular Data Registry (NCDR). The NCDR provides a comparison of our practice patterns and outcomes to national and peer group benchmarks. The service allows us to support local quality improvement programs, communicate with regulatory and contracting organizations, and improve patient care. The cath summary reporting application automatically integrates cath images from the system. HIS information also automatically flows into the cath lab applications. In particular, HIS patient scheduling and demographics are incorporated into our TCS workstations, courtesy of a ADT “ HL7 link. This link has become the industry standard HIS gateway, allowing us to pick up important data and save on duplicate information entry. Web Enablement We rely on a web interface for sharing cath and echo information throughout the hospital. The information is available to any authorized user on an intranet or the Internet via a web browser. The system’s MD Web module transforms images and reports generated in the cath and echo labs’ TCS software to standard Windows format for web publication. This requires no change in image acquisition or workflow. Once published to the web, images can be viewed immediately by doctors throughout Providence Southfield, Novi, and Livonia locations over the hospital’s web-based virtual private network (VPN). This is a secure in-house network that relies on existing Internet connections. A one-time plug-in installation enables image manipulation on a standard Web browser that is similar to manipulation on a dedicated viewing workstation. Our doctors, referring physicians, and any authorized user anywhere in the world can access cardiology images and information for telecardiology purposes by accessing the VPN over the Internet. Living by DICOM Our system utilizes the DICOM format for storing both cath and echo images. Originating in radiology, DICOM now provides a consistent format for image storage across most modalities. As medicine moves toward the virtual patient record, DICOM compliance will become increasingly important. Increasing Efficiencies Everyone involved in the project, from physicians and technologists to the IT team and management, has been extremely pleased with the results. Since the cath go-live date in September 2001, we have seen important benefits in the cath lab, as well as other areas of the hospital. First and foremost, we have accomplished our goal of creating an integrated cath lab record and all the efficiencies that entails. In labs that were film-based, time spent filing and retrieving reports then matching them with film, has been eliminated. Now these reports are created while the patient is on the table. When the study is completed, the report also is completed, minimizing disruption. Delays for transcription have been eliminated. Naturally, eliminating film in several labs provided all the typical benefits of filmless acquisition, from saving time and costs associated with processing and storage, to using technologists more efficiently. Room turnover has improved in labs converted from film to digital. As Dr. Delano Small, medical director of CCU put it, Making rounds in CCU is much more efficient. We are able to show the residents the cath and echo images without leaving the unit. Greater Accessibility Workflow has improved markedly as a result of information accessibility throughout the hospital. Physicians can review cases any time, anywhere inside the enterprise and outside utilizing telecardiology and web features. In particular, the ability to read cases right in the CCU, emergency room, and other patient care units has greatly improved efficiencies. Physicians have commented on the important benefits to their communications with families. Family members can now view images on computers in patient areas and see test results firsthand. Telecardiology also enables image exchange between Novi, Livonia, and the main Southfield Campus, as well as centralizing the archiving function. As a teaching facility, Providence has a cardiovascular residency program, which has reaped significant benefits from the project. Cases are now available for immediate review, allowing for more efficient use of time. Also, procedures to be presented during a conference can be selected ahead of time and retrieved without delay during the event. When a patient has to return to Providence Hospital for an additional intervention or repeat procedure, the physician can review the previous case on a computer terminal in the procedure room. This eliminates the need for the physician to break scrub to review old cases, as well as possible delays if a physician is busy reviewing a case in a remote location. It also eliminates unnecessary repeat angiography, which results in lower radiation exposure and contrast for the patient. The Future What’s next on our digital horizon? We will shortly be implementing Medcon’s eMedcon Internet referral service. With this service, doctors log on to a customized website and exchange digital studies for reading and second opinions. The process requires no dedicated software at the user’s end. We believe it will serve as an important marketing tool for our practice and enable us to maintain better contact with our referrals. We will also be building a new, dedicated heart center, housing all invasive and non-invasive departments. This will significantly expand our practice and will require a relocation. We also plan to add additional procedure rooms. We feel our system provides the flexibility to support reconfiguration after the move. With much of the reading outside the cath and echo labs taking place on standard personal computers, reorganizing the system should be simple. As Providence migrates toward increased cardiac digital management, our next step may be to add electrophysiology data to the system, as well as a DICOM interface for a radiology PACS query/ retrieve feature.

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